Medical Service Consent Form
DEPARTMENT OF CHILDREN AND FAMILIES
Division of Safety and Permanence
MEDICAL SERVICES CONSENT
Use of form: Use of this form is voluntar y, but completion will aid caretakers in ensuring that appropriate and timely health care is pro vided.
The form is to be completed by the parent or guardian of a child placed in foster care or treatment foster care. Personall y identifiable
information on this form wi ll be used for identification purp oses and to assure appropriate medical care for the child. Personal information you
provide may be used for secondary purpos es [Privacy Law, s. 15.04(1)(m), Wisconsin Statutes].
Instructions: If additional space is needed, attach a separate sheet or use reverse si de of this form.
Name – Parent or Guardian (Last, First, MI)
Name – Child (Last, First, MI)
Birthdate – Child (mm/dd/yyyy)
A. Routine Medical Services Consent and Exclusions
For purposes o f routine medical servic es for the above named child, I hereby give my consent for the chil d placing agency or its designee to
approve the provision of routine med ical services*, inc luding medical an d dental examinations and nonemergency prescribed treatments (e.g.,
tooth repair, immunizations, medications, repr oductive health needs assessment), with the following exceptions:
* All medical services will be under the dir ection of a licens ed dental care provider or physician or other l icensed professional as appro priate.
B. Routine Emergency Medical Services Consent and Exclusions
In case of a medical emer gency involving the above named chi ld, I understand that the following procedures will be used. I hereby give my
consent for the child placi ng agency or its design ee to arrange for emergency medical services using the following procedures:
1. A reasonable e ffort will b e ma de to contact me and secure my consent for needed medical services, in cluding surgical
procedures.
2. If I cannot be located within a reasonabl e time, the placing agenc y has the authority to consent to emer gency surgery.
3. The juvenil e co urt has the authority to consent to other med ical services.
4. All medical ser v ices will be under the direction of a licensed dental care provider or p hysician or other licensed pr ofessional as
appropriate.
I have no object ions to the placing age ncy exercising its authority, with the follo wing exceptions:
C. Parent / Guardian Information
Address – Home (Street, City, State, Zip Code)
Telephone Number – Home
Address – Work (Street, City, State, Zip Code)
Telephon e Number – Work
Address – Other (Specif y)
Telephon e Number – Other (Specify)
Address – Other (Specif y)
Telephon e Number – Other (Specify)
SIGNATURE – Parent / Guardian
Date Signed
SIGNATURE – Child (age 14 and over only)
Date Signed
DCF-F-CFS0997 (R. 07/2010)
Page 1/1
Free Download
Medical Service Consent Form PDF
Favor this template? Just fancy it by voting!
(0 Votes)
0.0
Related Forms
